Cal. Code Regs. Tit. 22, § 53887 - Exemption from Plan Enrollment
(a) An eligible beneficiary meeting the
criteria specified in section
53845(a), who
satisfies the requirements in (1) or (2) below, may request fee-for-service
Medi-Cal for up to 12 months as an alternative to plan enrollment by submitting
a request for exemption from plan enrollment to the Health Care Options Program
as specified in (b) below.
(1) An eligible
beneficiary who is an American Indian as specified in section
55100(i), a
member of an American Indian household, or chooses to receive health care
services through an Indian Health Service facility and has written acceptance
from an Indian Health Service facility for care on a fee-for-service
basis.
(2) An eligible beneficiary
who is receiving fee-for-service Medi-Cal treatment or services for a complex
medical condition, from a physician, a certified nurse midwife, or a licensed
midwife who is participating in the Medi-Cal program but is not a contracting
provider of either plan in the eligible beneficiary's county of residence, may
request a medical exemption to continue fee-for-service Medi-Cal for purposes
of continuity of care.
(A) For purposes of
this section, conditions meeting the criteria for a complex medical condition
include, and are similar to, the following:
1.
An eligible beneficiary is pregnant.
2. An eligible beneficiary is under
evaluation for the need for an organ transplant; has been approved for and is
awaiting an organ transplant; or has received a transplant and is currently
either immediately post-operative or exhibiting significant medical problems
related to the transplant. Beneficiaries who are medically stable on
post-transplant therapy are not eligible for exemption under this
section.
3. An eligible beneficiary
is receiving chronic renal dialysis treatment.
4. An eligible beneficiary has tested
positive for HIV or has received a diagnosis of acquired immune deficiency
syndrome (AIDS).
5. An eligible
beneficiary has been diagnosed with cancer and is currently receiving
chemotherapy or radiation therapy or another course of accepted therapy for
cancer that will continue for up to 12 months or has been approved for such
therapy.
6. An eligible beneficiary
has been approved for a major surgical procedure by the Medi-Cal
fee-for-service program and is awaiting surgery or is immediately
post-operative.
7. An eligible
beneficiary has a complex neurological disorder, such as multiple sclerosis, a
complex hematological disorder, such as hemophilia or sickle cell diseases, or
a complex and/or progressive disorder not covered in 1. through 6. above, such
as cardiomyopathy or amyotrophic lateral sclerosis, that requires ongoing
medical supervision and/or has been approved for or is receiving complex
medical treatment for the disorder, the administration of which cannot be
interrupted.
8. An eligible
beneficiary is enrolled in a Medi-Cal waiver program that allows the individual
to receive sub-acute, acute, intermediate or skilled nursing care at home
rather than in a sub-acute care facility, an acute care hospital, an
intermediate care facility or a skilled nursing facility.
9. An eligible beneficiary is participating
in a pilot project organized and operated pursuant to sections
14087.3,
14094.3,
or
14490
of the Welfare and Institutions Code.
(B) A request for exemption from plan
enrollment based on complex medical conditions shall not be approved for an
eligible beneficiary who has:
1. Been a member
of either plan on a combined basis for more than 90 calendar days,
2. A current Medi-Cal provider who is
contracting with either plan, or
3.
Begun or was scheduled to begin treatment after the date of plan
enrollment.
(3)
Except for pregnancy, any eligible beneficiary granted a medical exemption from
plan enrollment shall remain with the fee-for-service provider only until the
medical condition has stabilized to a level that would enable the individual to
change physicians and begin receiving care from a plan provider without
deleterious medical effects, as determined by a beneficiary's treating
physician in the Medi-Cal fee-for-service program, up to 12 months from the
date the medical exemption is first approved by the Health Care Options
Program. A beneficiary granted a medical exemption due to pregnancy may remain
with the fee-for-service Medi-Cal provider through delivery and the end of the
month in which 90 days post-partum occurs.
(4) Any extension to the 12-month medical
exemption time limit shall be requested through the Health Care Options Program
no earlier than 11 months after the starting date of the exemption currently in
effect. The Health Care Options Program will notify the beneficiary 45 days
before the expiration of an approved medical exemption and will inform the
beneficiary how to request an extension. An extension to the medical exemption
shall be approved if the eligible beneficiary continues to meet the
requirements of subsection (a)(2).
(b) Exemption from plan enrollment or
extension of an approved exemption due to a complex medical condition, as
specified in (a)(2)(A), shall be requested on the "Request for Medical
Exemption from Plan Enrollment" form (HCO Form 7101, June 2000), hereby
incorporated by reference, which is available from the Health Care Options
Program. Exemption from plan enrollment or extension of an approved exemption
due to a beneficiary's enrollment in a Medi-Cal waiver program, as specified in
(a)(2)(A)8, or a beneficiary's acceptance for care at an Indian Health Service
facility, as specified in (a)(1), shall be requested on the "Request for
Non-Medical Exemption from Plan Enrollment" form (HCO Form 7102, October 2000),
hereby incorporated by reference, which is available from the Health Care
Options Program. The completed request for exemption shall be submitted to the
Health Care Options Program by the Medi-Cal fee-for-service provider or the
Indian Health Service facility treating the beneficiary and shall be submitted
by mail or facsimile. Request for exemption from plan enrollment or extension
of an approved exemption shall not be submitted by the plan.
(c) The Health Care Options Program, as
authorized by the department, shall approve each request for exemption from
plan enrollment that meets the requirements of this section. At any time, the
department may, at its discretion, verify the complexity, validity, and status
of the medical condition and treatment plan and verify that the provider is not
contracted or otherwise affiliated with a plan. The Health Care Options
Program, as authorized by the department, or the department may deny a request
for exemption from plan enrollment or revoke an approved request for exemption
if a provider fails to fully cooperate with this verification.
(d) Approval of requests for exemption from
plan enrollment is subject to the same processing times and effective dates
specified in section
53889 for the processing of
enrollment and disenrollment requests.
(e) The Health Care Options Program, as
authorized by the department, or the department may revoke an approved request
for exemption from plan enrollment at any time if the department determines
that the approval was based on false or misleading information, the medical
condition was not complex, treatment has been completed, or the requesting
provider is not or has not been providing services to the beneficiary. The
department shall provide written notice to the beneficiary that the approved
request for exemption from plan enrollment has been revoked and shall advise
the beneficiary that they must enroll in a Medi-Cal plan and how that
enrollment will occur, as specified in section
53882. The revocation of an
approved request for exemption from plan enrollment shall not otherwise affect
an eligible beneficiary's eligibility or ability to receive covered services as
a plan member.
Notes
2. Repealer of section and NOTE and new section and NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).
3. Amendment of subsections (b), (b)(4) and (c) filed 10-1-97 as an emergency; operative 10-1-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 40).
4. Repealer and new section heading, section and NOTE filed 12-19-2000 as an emergency; operative 12-19-2000. Submitted to OAL for printing only pursuant to section 147, SB 485 (Ch. 722/92) (Register 2000, No. 51).
5. Governor Newsom issued Executive Order N-55-20 (2019 CA EO 55-20), dated April 22, 2020, which suspended provisions under this section that prevent the extension of deadlines for fee-for-service providers to submit information required for a Medical Exemption Request, due to the COVID-19 pandemic.
Note: Authority cited: Sections 10725, 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 14087.3 and 14087.4, Welfare and Institutions Code.
2. Repealer of section and Note and new section and Note filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).
3. Amendment of subsections (b), (b)(4) and (c) filed 10-1-97 as an emergency; operative 10-1-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 40).
4. Repealer and new section heading, section and Note filed 12-19-2000 as an emergency; operative 12-19-2000. Submitted to OAL for printing only pursuant to section 147, SB 485 (Ch. 722/92) (Register 2000, No. 51).
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